Laparoscopic Cholecystectomy in Situs Inversus Totalis with Stage 5 Chronic Kidney Disease: A Case Report

Situs inversus totalis is a rare congenital anomaly in which the abdominal and thoracic organs are transposed in a mirror image. Diagnosis and management of cholelithiasis in patients with situs inversus totalis pose a challenge due to the anatomical variation. A laparoscopic cholecystectomy in such a case can be technically challenging, especially for a right-handed surgeon. In this case report, we present a case of a 38-year-old male with symptomatic cholelithiasis in a chronic kidney disease stage five patient under maintenance hemodialysis planned for recipient renal transplant. A laparoscopic cholecystectomy considered the gold standard for symptomatic cholelithiasis was performed with a three-port technique. The technical challenges anticipated due to anatomical variation were managed by intraoperative modifications. In conclusion, laparoscopic cholecystectomy in patients with situs inversus totalis can be done with technical modifications and re-orientation of visual motor skills

Visualisation of Rouviere’s Sulcus during Laparoscopic Cholecystectomy

Introduction: Safe dissection of Calot’s Triangle is important during the performance of laparascopic cholucystectomy. The purpose of the study is to determine the frequency of demonstrable Rouviere’s sulcus in patients with symptomatic gall stones and its role in safe dissection in Calot’s triangle. Methods: This is a prospective descriptive study design done in Department of surgery, Kathmandu Medical College Teaching Hospital from Jan 2013 to Jan 2015. Patients who were posted for laparoscopic cholecystectomy were included. During laparoscopy, Rouviere’s sulcus was noted in the operative note and classified according to following: Type I: Open type was defined as a cleft in which the right hepatic pedicle was visualized and the sulcus was opened throughout its length. Type II: if the sulcus was open only at its lateral end. Type III If the sulcus was open only at its medial end. Type IV: Fused type was defined as one in which the pedicle was not visualized. Results: A total of 200 patients underwent laparoscopic cholecystectomy during period of 2 years. Out of which Rouviere’s sulcus was visualized in 150 patients (75 %).Type I (open type) was commoner in 54%, type II in 12%, Type III in 9% and type IV (fused type) in 25%. Conclusions: Rouviere’s Sulcus is an important extra biliary land mark for safe dissection of Calot’s triangle during laparoscopic cholecystectomy.  Keywords: Rouviere’s Sulcus, laparoscopic cholecystectomy, bile duct injury

Visualisation of Rouviere’s Sulcus during Laparoscopic Cholecystectomy

Introduction: Safe dissection of Calot’s Triangle is important during the performance of laparascopic cholucystectomy. The purpose of the study is to determine the frequency of demonstrable Rouviere’s sulcus in patients with symptomatic gall stones and its role in safe dissection in Calot’s triangle. 
 Methods: This is a prospective descriptive study design done in Department of surgery, Kathmandu Medical College Teaching Hospital from Jan 2013 to Jan 2015. Patients who were posted for laparoscopic cholecystectomy were included. During laparoscopy, Rouviere’s sulcus was noted in the operative note and classified according to following: Type I: Open type was defined as a cleft in which the right hepatic pedicle was visualized and the sulcus was opened throughout its length. Type II: if the sulcus was open only at its lateral end. Type III If the sulcus was open only at its medial end. Type IV: Fused type was defined as one in which the pedicle was not visualized. 
 Results: A total of 200 patients underwent laparoscopic cholecystectomy during period of 2 years. Out of which Rouviere’s sulcus was visualized in 150 patients (75 %).Type I (open type) was commoner in 54%, type II in 12%, Type III in 9% and type IV (fused type) in 25%. 
 Conclusions: Rouviere’s Sulcus is an important extra biliary land mark for safe dissection of Calot’s triangle during laparoscopic cholecystectomy. 
 Keywords: Rouviere’s Sulcus, laparoscopic cholecystectomy, bile duct injury

Effectiveness of 0.2% Glyceryl trinitrate and 0.5% Nifedipine in the Treatment of Chronic Anal Fissure

Introduction: Anal fissure is an ischemic ulcer caused by combination of spasm of internal anal sphincter and poor blood supply to the posterior midline of anal canal. This study aimed to assess the efficacy of Glyceryl Trinitrate and Nifedipine in the treatment of chronic anal fissure. Methods: Ninety patients with symptomatic anal fissure in Kathmandu Medical College Teaching Hospital are allocated for study in two groups of 45 each from March 2013 to April 2014. The patients are assigned alternatively to GTN group and Nifedipine group. All patients were assessed every week till 8 weeks in regards to headache, compliance, healing and recurrence. The patients who had complete healing in 8 weeks were further followed up for 6 weeks to detect recurrence. Results: Patients in the two groups were comparable in regard to demographic data (age and sex) as well as clinical factors. Headache was main complaint of patients using GTN in high percentage (16.6%) than complained by patients using topical Nifedipine (6.9%). This factor led to poor compliance with GTN compared with Nifedipine.  Nifedipine showed better healing rate 82.5% compared with GTN 60%. Recurrence was comparable among the two groups. Conclusions: Nifedipine ointment showed better results than GTN ointment in chronic anal fissure regarding headache, compliance, healing and recurrence in 6 weeks of follow up period after complete healing of fissure in 8 weeks. Keywords: anal fissure; glyceryl trinitrate; nifedipine

Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort study

Background Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC).Methods The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity.Findings On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84-1.29], p = 0.711 and HR 1.18 [0.95-1.46], p = 0.13 respectively) or OS (HR 0.96 [0.79-1.17], p = 0.67 and HR 1.48 [1.16-1.88], p = 0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02-1.74], p = 0.037) and OS (HR 1.26 [1.03-1.53], p = 0.022). Furthermore, EBDR (OR 2.86 [2.3-3.52], p < 0.0010), resection of additional organs (OR 2.22 [1.62-3.02], p < 0.0010) and major hepatectomy (OR 3.81 [2.55-5.73], p < 0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02-1.37], p = 0.031) but not OS (HR 1.05 [0.91-1.22], p = 0.48). Adjuvant and neoadjuvant treatments were infrequently used.Interpretation In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international col-laborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit.Funding Cambridge Hepatopancreatobiliary Department Research Fund.Copyright & COPY; 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)